Healthcare Provider Details

I. General information

NPI: 1306088455
Provider Name (Legal Business Name): J&J STATE STREET PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 STATE ST
HACKENSACK NJ
07601-5515
US

IV. Provider business mailing address

298 STATE ST
HACKENSACK NJ
07601-5515
US

V. Phone/Fax

Practice location:
  • Phone: 201-820-3360
  • Fax:
Mailing address:
  • Phone: 201-820-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number28RS00688900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0207993
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier3195674
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER

VIII. Authorized Official

Name: JAMES DEMICCO
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 201-981-1144